Dosefinding trial studying effect of 4 weeks Intervention on safety and efficacy in males with Metabolic syndrome treated with oral Eubacterium hallii

Also see p. 6, 7, 8 in protocol.
Accumulating data from both patients and animal models indicate that imbalances
in the composition of the gut microbiota are related to obesity and its
associated diseases. We recently published that lean donor gut microbiota
infusion was associated with an increase of E. hallii concentrations in the
(small) intestine, with the increase in E. hallii being directly correlated
with improvement in (peripheral) insulin sensitivity (r=0.7, p<0.05).
Eubacterium hallii is a butyrate-producing species, but in contrast to other
well-known human isolates such as Roseburia and Faecalibacterium spp. that
produce butyrate from sugars, E. hallii has the capacity to produce butyrate
from lactate in an acid environment (pH 1-2) as found in the small intestine.
This makes it very plausible that this bacterial strain can survive stomach
passage while being exposed to low pH values. Moreover, E. hallii has the
capability to convert a potentially damaging acid (e.g. lactic acid) into other
short chain fatty acid butyrate (which is known to exert beneficial effects on
glucose metabolism and liverfat.

To further investigate the safety and efficacy of oral E. hallii L2-7
supplementation, we have performed a 4 week daily oral dose finding study in an
animal model of insulin resistance with an E. hallii L2-7 strain DSM 17630. We
found that increasing dosage of daily E. hallii treatment at 10e6, 10e8
10e10,cells/ml (100ul of each dose) versus placebo (glycerol 10% solution) was
safe and did not induce adverse effects (see product dossier). Moreover we
observed a dose dependent effect of E. hallii on improved insulin sensitivity
(ITT fig 2a) in correspondence with fecal E. hallii levels (fig 2b) and genes
of NASH/NAFLD in these mice (see figure 2c, also in IMPD).
While knowledge regarding the relationship between bacterial species and
metabolism in rodent models is rapidly increasing, causality about involved
strains of gut microbiota in human metabolism is limited. Thus, in this human
phase I/II trial we will try to further expand our knowledge by reproducing
these animal data in relation to safety and optimal oral daily dosage of E.
hallii treatment on various aspects of metabolism in male subjects with
metabolic syndrome. As fecal transplantation studies currently performed at our
department render important data on the driving causal pathophysiologic
mechanisms driving insulin resistance, its nature precludes widespread
clinical use. We thus postulate that insulin sensitivity (normalised
gluconeogenesis and improved peripheral/muscle insulin sensitivity) as well as
lipolysis can be improved by 4 weeks daily oral treatment with E. hallii via
altered bile acid metabolism. As a consequence, liver fat content (NAFLD/NASH
on liver MRI) will decrease.

To investigate different dosages of 4 weeks oral Eubacterium hallii treatment
on safety and efficacy parameters.

This is a phase II single center open randomized controlled trial in which we
will perform dose finding study. Patients will be randomized to the following 3
treatment arms:
1.Once daily treatment with Eubacterium hallii 100 ml at concentration of 10e7
cells/vial for 4 weeks (n=9)
2. Once daily treatment with Eubacterium hallii 100 ml at concentration of 10e9
cells/vial for 4 weeks (n=9)
3. Once daily treatment with Eubacterium hallii 100 ml at concentration of
10e11 cells/vial for 4 weeks (n=9)

Subjects will be given 100 ml Eubacterium halli suspension per day for 28 days.
Increasing dosages of 10e7, 10e9 and 10e11 cells/ vial(dissolved in total
volume of 100ml milk) will be tested (n=9 subjects per dosage). The safety of
each dosage will be assessed by vital signs, liverfunction tests before
introducing the higher dose. Efficacy will be tested by Eubacterium hallii in
feces and effects on insulin sensitivity.

Total study duration is 6 weeks with a total time per subject of 18 hours. In
total 270ml blood will be sampled during 2 hyperinsulinemic clamps and 5
venapunctures, 5 stool samples collected and two MRIs of the liver performed.
Risk assessment is moderate:
- During the hyperinsulinemic clamp there is a risk for hypoglycaemia. This is
minimised by close monitoring of plasma glucose levels, every 5-10 minutes.
- Eubacterium Hallii: Considering the effects of a short term intervention with
E.Hallii in mice it seems unlikely that patients will suffer any side effects.
Possible side effects could theoretically consist of temporary flatulence or
stomachache.To ensure complete patient safety, we have chosen to use a single
blinded dose finding study design, by which the investigators have full access
to clinical efficacy and safety data during increasing dosages of E.hallii.